• rib fractures

Surgical stabilization of rib fractures (SSRF) is now a well-established and evidence-based approach for management of patients with respiratory impairment due to flail chest.1 2 In addition to management of flail chest, some studies suggest a beneficial role of SSRF in patients with severe, but non-flail, rib fractures,3 although this remains controversial.4

Regardless of the indication for SSRF, there are no studies to guide the operative technique to be used based on fracture pattern. Currently, five commercially available systems constitute the overwhelming majority of implants that are used. Of these five, only one uses an intrathoracic approach. Proponents of this approach suggest that this technique allows for appropriate reduction and stabilization fractures without the need for more extensive soft tissue dissection associated with an extrathoracic operative approach and it provides for a more stable construct by directing the forces of chest wall movement against the plate (ie, pushing the plate into the bone). Moreover, the intrathoracic technique allows for reduction of posterior fractures that cannot be stabilized from an extrathoracic approach due to proximity to the spinous processes. But, these potential benefits have to be weighed against the need for video assisted thoracoscopic surgery and thus single lung ventilation. To date, there are no studies directly comparing clinical outcomes between any of the implants.

In this study, Tichenor et al sought to measure the impact of intrathoracic versus extrathoracic SSRF on pain control.5 Patients underwent SSRF based on surgeon discretion. There was no way to control for degree of chest muscle dissection in either approach. Postoperative pain control was opioid based, no patient received regional analgesia, and the authors do not comment on non-opioid-based therapies such as acetaminophen or non-steroidal anti-inflammatory drug (NSAID) use. The authors noted a near 50% reduction in daily morphine equivalent narcotic use in the cohort that underwent intrathoracic plating. The difference remains significant after controlling for sex, injury severity score (ISS), number of broken ribs, lung injury, and Glasgow Coma Scale Score.

The authors are to be commended for carrying out this needed study. However, as they themselves point out, there are numerous limitations that preclude the results from being generalizable. Issues such as likely variability in postoperative pain control regimen, inability to analyze incision length or dissection methodology in both cohorts, and small sample size, which may have masked significant differences in baseline demographics and injury patterns, are key issues. Nonetheless, this study informs future investigators of issues that need to be addressed and further supports the need for a prospective, appropriately powered trial to compare outcomes using these two very different operative approaches. Tichenor’s results, as well as those of previous investigators, should be used to analyze the sample size needed for such a study. As with most things in medicine, it is likely that there is no “one size fits all” approach to SSRF and patient selection will likely be key in determining optimal outcomes based on operative approach.